Government of New York

STATE OF NEW YORK WORKERS' COMPENSATION BOARD

100 BROADWAY-MENANDS ALBANY, NY 12241 (877) 632-4996

You were injured at work. What now?

If you've suffered a workplace injury or illness, you may be eligible for workers' compensation benefits. You may have already received medical treatment. If you haven't, you should seek medical care as soon as possible.

A Worker's Responsibilities ? You must tell your employer, in writing, when, where and how you were injured.

Do this within 30 days of injury. ? Medical reports are necessary for your case. Advise your doctors that you have a work-

related injury, and give the name of your employer. Do not pay for your care yourself or use other health insurance. Tell your doctor to file reports with the Board and with your employer or its insurance carrier. If your case is disputed, the Board needs a medical report on your injury to begin resolving your claim.

Starting a Case Once your employer knows of your injury, it must notify this Board. You should file an employee claim (C-3 form) reporting your injury as soon as possible. (You must notify the Board of your injury or illness within two years.) If you injured the same body part before, or had a similar illness, you must also file a Form C-3.3.

If you haven't already filed a C-3 or C-3.3 (if necessary), there are three ways to do it.

? Visit wcb.content/main/onthejob/howto.jsp to complete the form. ? Complete the enclosed paper forms, and mail them to the Board. ? Call 1-866-396-8314. A Board employee will complete the form with you.

Health Care Bills Do not pay your doctor or hospital. Those bills are paid by the insurer unless the Board disallows your case. If your case is disputed, the providers are paid when the Board decides your case. If the Board decides against you, or if you don't pursue a case, you will have to pay the doctor or hospital.

Your employer's insurance covers medically necessary drugs and equipment your doctor prescribes. You're also entitled to carfare or necessary expenses incurred when traveling for treatment. (Get receipts for those expenses.)

THIS AGENCY EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION

Claimant Information Packet

Generally, you can choose any doctor authorized by the Board. You can also use occupational health clinics. However, if your employer's insurer has a preferred provider organization to provide care for workers' compensation injuries, you must get your initial treatment from those providers. If that insurer also has a pharmacy or diagnostic network, you must get service within these networks. If the carrier uses these networks, it must also tell you its service providers and how to use them.

Benefits for Lost Wages You are entitled to a portion of your lost wages if your injury affects you in one or more ways:

1. It keeps you from work for more than seven days; 2. Part of your body is permanently disabled; 3. Your pay is reduced because you now work fewer hours or do other work.

An employer or insurer can accept your claim and begin paying your lost wage benefit promptly. Sometimes, employers and carriers dispute a claim. When that occurs, the Board strives to resolve most cases within 90 days.

You may hire an attorney or licensed representative, who can be helpful with complex or disputed claims, but it isn't required. The Board sets their fees and they will be deducted from your lost wages award. You or your family should not pay anything directly to your attorney or licensed representative.

If your case is disputed, you may receive disability benefits while the case is heard. You'd pay them back out of your lost wages award. To get a DB-450 form, visit wcb.content/main/forms/db450.pdf or a Board office, or call (800) 353-3092.

Help is Available People sometimes need help getting back to work. An injury can also cause family or financial problems. The Workers' Compensation Board has rehabilitation counselors and social workers to help. Call (877) 632-4996 for more assistance.

What's Next? Your employer or its insurance carrier will contact you if your claim is accepted. Your employer may have a return to work program that can get you back to work in light duty or an alternative position while you heal. When that happens, your treatment will be paid and lost wage benefits begin. If your case is challenged, the Board will notify you about resolving the case. If more information is necessary, the Board will contact you and tell you how to file it.

Important Contact Information Workers' Compensation Board Disability Benefits NYS Bar Association Lawyer Referral and Information Service

(877)632-4996 (800)353-3092 (800)342-3661

General_Information@WCB. WCB. lr@.

NEW YORK STATE WORKERS' COMPENSATION BOARD

Employee Claim

State of New York - Workers' Compensation Board

C-3

Fill out this form to apply for workers' compensation benefits because of a work injury or work-related illness. Type or

print neatly. This form may also be filled out on-line at wcb..

WCB Case Number (if you know it):

A. YOUR INFORMATION (Employee)

1. Name:

First

MI

Last

2. Date of Birth: ______/______/______

3. Mailing address: 4. Social Security Number:

Number and Street/PO Box

- -

City

State

5. Phone Number: (_____)_______________ 6. Gender:

Zip Code

Male

Female

7. Will you need a translator if you have to attend a Board hearing? Yes No If yes, for what language?

B. YOUR EMPLOYER(S)

1. Employer when injured:

2. Phone Number: (_____)_______________

3. Your work address:

Number and Street

City

4. Date you were hired: _____/_____/_____ 5. Your supervisor's name:

State

Zip Code

6. List names/addresses of any other employer(s) at the time of your injury/illness:

7. Did you lose time from work at the other employment(s) as a result of your injury/illness?

Yes

No

C. YOUR JOB on the date of the injury or illness

1. What was your job title or description?

2. What types of activities did you normally perform at work?_________________________________________________________________

3. Was your job? (check one)

Full Time

Part Time

4. What was your gross pay (before taxes) per pay period?

6. Did you receive lodging or tips in addition to your pay? Yes

Seasonal

Volunteer

Other:____________________

5. How often were you paid?

No If yes, describe:

D. YOUR INJURY OR ILLNESS

1. Date of injury or date of onset of illness: ______/______/______

2. Time of injury:

3. Where did the injury/illness happen? (e.g., 1 Main Street, Pottersville, at the front door)

AM

PM

4. Was this your usual work location? Yes No If no, why were you at this location? 5. What were you doing when you were injured or became ill? (e.g., unloading a truck, typing a report) _______________________________

6. How did the injury/illness happen? (e.g., I tripped over a pipe and fell on the floor)

7. Explain fully the nature of your injury/illness; list body parts affected (e.g., twisted left ankle and cut to forehead):______________________

C-3.0 (1-11) Page 1 of 2

THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION

wcb.

YOUR NAME:________________________________________________

First

MI

Last

D. YOUR INJURY OR ILLNESS continued

8. Was an object (e.g., forklift, hammer, acid) involved in the injury/illness?

DATE OF INJURY/ILLNESS: ______/______/______ Yes No If yes, what?

9. Was the injury the result of the use or operation of a licensed motor vehicle? Yes No

If yes, your vehicle

employer's vehicle

other vehicle License plate number (if known):

If your vehicle was involved, give name and address of your motor vehicle insurance carrier:

10. Have you given your employer (or supervisor) notice of injury/illness?

Yes No

If yes, notice was given to: ____________________________________ orally in writing Date notice given: _____/_____/_____

11. Did anyone see your injury happen? Yes No Unknown If yes, list names:________________________________________

E. RETURN TO WORK

1. Did you stop work because of your injury/illness?

Yes, on what date? _____/_____/_____

No, skip to Section F.

2. Have you returned to work? Yes No If yes, on what date? _____/_____/_____

regular duty

limited duty

3. If you have returned to work, who are you working for now?

Same employer

New employer

Self employed

4. What is your gross pay (before taxes) per pay period?

F. MEDICAL TREATMENT FOR THIS INJURY OR ILLNESS

How often are you paid?

1. What was the date of your first treatment? ______/______/______

None received (skip to question F-5)

2. Were you treated on site? Yes No

3. Where did you receive your first off site medical treatment for your injury/illness?

none received

Emergency Room

Doctor's office

Clinic/Hospital/Urgent Care

Hospital Stay over 24 hours

Name and address where you were first treated:

Phone Number: (_____)_______________

4. Are you still being treated for this injury/illness?

Yes No

Give the name and address of the doctor(s) treating you for this injury/illness:

Phone Number: (_____)_______________

5. Do you remember having another injury to the same body part or a similar illness? Yes

No

If yes, were you treated by a doctor? Yes No If yes, provide the names and addresses of the doctor(s) who treated you and COMPLETE AND FILE FORM C-3.3 TOGETHER WITH THIS FORM:

6. Was the previous injury/illness work related?

Yes No

If yes, were you working for the same employer that you work for now?

Yes

No

I am hereby making a claim for benefits under the Workers' Compensation Law. My signature affirms that the information I am providing is true and accurate to the best of my knowledge and belief.

Any person who knowingly and with INTENT TO DEFRAUD presents, causes to be presented, or prepares with knowledge or belief that it will be presented to, or by an insurer, or self-insurer, any information containing any FALSE MATERIAL STATEMENT or conceals any material fact, SHALL BE GUILTY OF A CRIME and subject to substantial FINES AND IMPRISONMENT.

Employee's Signature:

Print Name:

Date: _____/_____/_____

On behalf of Employee:

Print Name:

Date: _____/_____/_____

An individual may sign on behalf of the employee only if he or she is legally authorized to do so and the employee is a minor, mentally incompetent or incapacitated.

I certify to the best of my knowledge, information and belief, formed after an inquiry reasonable under the circumstances, that the allegations and other factual matters asserted above have evidentiary support, or are likely to have evidentiary support after a reasonable opportunity for further investigations or discovery.

Signature of Attorney/Representative (if any):

Date: _______/_______/_______

Print Name:

Title:

ID No., if any: R C-3.0 (1-11) Page 2 of 2

If Licensed Representative, License No.:

Expiration Date: _______/_______/_______

Limited Release of Health Information

(HIPAA)

State of New York - Workers' Compensation Board

C-3.3

WCB Case No. (if you know it):___________________________

To Claimant: If you received treatment for a previous injury to the same body part or for an illness similar to the one described in your current Claim, fill out this form. This form allows the health care providers you list below to release health care information about your previous injury/ illness to your employer's workers' compensation insurer. The federal HIPAA law (Health Insurance Portability and Accountability Act of 1996) says you have a right to get a copy of this form. If you do not understand this form, talk to your legal representative. If you do not have a legal representative, the Advocate for Injured Workers at the Workers' Compensation Board can help you. Call: 800-580-6665.

To Health Care Provider: A copy of this HIPAA-compliant release allows you to disclose health information. If you send records to the employer's workers' compensation insurer in response to this release, also mail copies to the Claimant's legal representative. (If no legal

representative is listed below, send copies to the Claimant.) Health care providers who release records must follow New York state law and

HIPAA.

This release is:

Voluntary. Your health care provider(s) must give you the same care, payment terms, and benefits, whether you sign this form or not.

Limited. It gives your health care provider(s) permission to release only those health records that are related to the previous illness/condition you describe below.

Temporary. It ends when your current claim for compensation is established or disallowed and all appeals are exhausted.

Revocable. You can cancel this release at any time. To cancel, send a letter to the health care provider(s) listed on this form. Also, send a copy of your letter to your employer's workers' compensation insurer and the Workers' Compensation Board. Note: You may not cancel this release with respect to medical records already provided.

For records only. It gives your health care provider(s) listed on this form permission to send copies of your health care records to your employer's workers' compensation insurer.

This form does NOT allow your health care provider(s) to release the following types of information:

HIV-related information

Psychotherapy notes

Alcohol/Drug treatment

Mental Health treatment (unless you check below)

Verbal information (your health care providers may not discuss your health care information with anyone)

Any medical records released will become part of your workers' compensation file and are confidential under the Workers' Compensation Law. A. YOUR INFORMATION (Claimant)

1. Name:__________________________________________________________________ 2. Social Security Number:______-_____-______ 3. Mailing Address: _________________________________________________________________________________________________ 4. Date of Birth: ______/______/______ 5. Date of the current injury/illness: ______/_______/_______ 6. Current injury/illness, including all body parts injured:_____________________________________________________________________

______________________________________________________________________________________________________________ 7. Your legal representative's name and address (if any):___________________________________________________________________

______________________________________________________________________________________________________________ Check here if you allow your health care provider(s) to release mental health care information.

B. YOUR HEALTH CARE PROVIDER(S) (List all health care providers who treated you for a previous injury to the same body part or similar illness. If more than 2 providers attach their contact information to this form.)

1. Provider:__________________________________________________________________ 2. Phone Number: (______)_______________ 3. Mailing Address: _________________________________________________________________________________________________ 4. Other provider (if any):_______________________________________________________ 5. Phone Number: (______)_______________ 6. Mailing Address:_________________________________________________________________________________________________

C. READ AND SIGN BELOW. I hereby request that the health care provider(s) listed above give my employer's workers' compensation insurer copies of all health records related to any previous injury/illness, to all body parts, described above.

____________________________________________________________________________________________________________

Claimant's signature (ink only -- use blue ballpoint pen, if possible.)

Date

If the claimant is unable to sign, the person signing on his/her behalf must fill out and sign below:

______________________________________________________________________________________________________________

Your name

Relationship to Claimant

Signature (ink only -- use blue ballpoint pen, if possible.)

Date

C-3.3 (12-09)

Versi?n en espa?ol al reverso de la forma.

wcb.

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